Suggested Pre-Referral Evaluation and Management Guidelines
Common dizziness scenarios:
1. Acute onset dizziness:
Most common cause is vestibular neuritis (labyrinthitis), but stroke should also be considered. If other neurologic symptoms or concern for stroke, would recommend referring patient to Emergency Room. For vestibular neuritis, consider the following: symptomatic treatment, a burst & taper of steroids, vestibular rehabilitation, and urgent outpatient appointment.
2. Recurrent Positionally Triggered Dizziness: Most common cause is benign paroxysmal positional vertigo (BPPV), which can be effectively treated with canalith repositioning maneuvers. If downbeating nystagmus seen or other neurologic features, consider central positional dizziness as the cause.
3. Recurrent Spontaneous Episodes of Dizziness: Dizziness attacks in Meniere's disease are characterized by severe vertigo and unilateral auditory symptoms. Low salt diet or diuretics are typical first line treatment options. Benign Recurrent Vertigo (typically considered a migraine equivalent) is characterized by vertigo attacks without prominent auditory features. The following measures may be effective: general lifestyle measures, symptomatic treatment, trials of migraine prophylactic medications. Transient Ischemic Attack (TIA) etiology should be considered when other neurologic features are reported, when the patient is at high risk for vascular events, or when episodes are new (particularly when minutes in duration). Patients with suspected TIA should be referred to the ER or for urgent outpatient neurology referral as indicated.
Other potential causes to consider:
Consider medication side effects, balance disorder cause by musculoskeletal problems or a neurological disorder (e.g., ataxia, Parkinson's disease), presyncope, migraine dizziness, panic disorder, peripheral neuropathy, or bilateral vestibulopathy.
Suggested Additional Test/Management Prior to Specialty Visit
No tests are required prior to referral. We are happy to evaluate patients and help decide what tests are indicated.